Wittgenstein and Freud

The frightening thing about madness is that people’s words and deeds lose their meaning. We can no longer relate to them as we normally relate to people. We cannot see their actions as the expression of reasonable intentions nor can we understand their statements as the expression of a reasonable attempt to make sense of the world and their experience of it. We have to give up (at least temporarily) on the attempt to understand what they do as the expression of the human being they are. The medical response to this terrible situation is to seek to identify the cause of the mental health issue and address it, or, if a specific cause cannot be identified, to make an intervention that in the past has been shown to help people in similar conditions return to a more normal state. Psychoanalysis takes a different approach. It continues to treat the mentally ill person’s words and deeds as significant. Whatever the person may say or do, psychoanalysis remains committed to the search for meaning. But it can only do this because it broadens our normal approach to understanding people and does not seek a unified meaning in what people say and do. Instead, it bases its approach on the idea that human beings often think and feel contradictory things. It claims that the best way to help people with (certain) mental health issues is to help them understand the internal conflicts that lead them to say and do contradictory things.

The distinctive nature of the psychoanalytical approach is brought out very well by the Oxfor philosopher, Edward Harcourt, in his essay, Madness, Badness and Immaturity. His argument applies broadly to psychoanalysis, but he focuses on relational (or object-relations) psychoanalysts (such as Klein, Winnicott, Bion, Loewald, Kohut and Mitchell). He notes that, although these psychoanalysts use different terminologies, they all contrast two ways of relating to other people (mergedness vs separateness, immature vs mature dependence, undifferentiation vs differentiation). In each case, the contrast is normative – the second term indicates where people ought to be. This contrast is used as a measure of maturity and of mental health. But, he asks, can one standard really fulfil both roles?

Pathological narcissism provides evidence for the defence, since it is plausible to argue both that narcissists have failed to develop properly and that they have a mental health problem. But Harcourt points out that, if the standard these analysts want to use is a maturity standard, this would imply that all infants are mad, which is highly implausible. Psychoanalysts claim that narcissists do not really know that other people exist, and some of them make a similar claim in relation to new-born infants, arguing that they cannot differentiate the self from the non-self. Harcourt challenges this on the basis that a normal baby’s response to the world demonstrates that it does not experience itself as boundaryless. His more fundamental point, however, is that it is not a matter of cognitive capabilities. Even pathological narcissists are aware intellectually that other people exist. If you ask them: “how many people are there in the world?”, they do not say: “one”. In fact, they are in some ways very sensitive to other people. They need them to feed their narcissism, and they worry that they might undermine it. The real issue is that they treat people badly. In Kantian terms, they treat them as means rather than ends. There is no recognition that they have their own desires, goals and feelings – no respect for their autonomy. These formulations bring out the ethical nature of the standard being applied. As Harcourt notes, this places psychoanalysis in “a philosophical tradition going back to Plato and Aristotle, which focuses on the connections between human nature, human excellence and the good life for human beings”.

Harcourt’s conclusion raises many interesting issues. The primary issue he focuses on is whether an ethical standard can be used as a development or maturity standard. If it could, this would imply that all babies are bad (fail ethically), which again seems highly implausible. Some psychoanalysts have in fact made claims along these lines. For example, Melanie Klein claimed destructive aggression was a primary human drive. To that extent, she claimed that all human beings are bad and that we are born bad.  But not all psychoanalysts make this claim (e.g. Winnicott did not). Furthermore, even Klein sees normal infants as reaching a position where they accept responsibility for their destructiveness and seek to make amends for it. So, even for Klein, infants overcome or at least mitigate their badness. If we return to the issue of recognising the separateness of other people, however, Harcourt is right that narcissists and infants are not in the same position in relation to the standard he discusses. Unlike narcissists, normal infants “really relate” to others even if what this involves takes a different form than in adults (e.g. they cannot express concern for their mother’s welfare). So, while we may see narcissists as failing ethically in their treatment of other people, this is not a claim we (or most psychoanalysts) would make in relation to infants. But this implies that the standard that psychoanalysts apply to narcissists (and to people with other kinds of mental health issues) cannot be used as a development standard.

But can it be used as a standard of mental health? Harcourt notes that if you believe that psychopathology classifications must be value-free, this rules out using an ethical standard. But he does not take a position on whether mental health standards can or should be value-free. Near the start of his essay, however, he notes that psychoanalysis no longer presents itself as a general theory of psychopathology and instead sees itself as focusing on a more limited area, e.g. “disorders of the self”. He seems sympathetic to this position and explicitly notes that he himself would not wish to argue that (e.g.) schizophrenia is a kind of ethical defect. My own view is that any sensible mental health standard will involve a reference to what is normal or reasonable and to that extent will not be value-free even if they are not as clearly ethical as the psychoanalytic standard Harcourt discusses. Like him, I would also be sympathetic to the idea that the psychoanalytic approach has limits, but not fixed limits. There is a parallel here with natural science. The claim that every event has a cause is not a necessary truth. It’s an injunction never to give up on the search for causes. If we cannot find a causal explanation for something, we should try harder, but there is no guarantee we will succeed (in the near or distant future). Similarly, in relation to human behaviour, we can always search for meaning, but there is no guarantee that we will succeed. In my view, there are definitely mental health issues that we can make sense of (explain using the sort of concepts we use to explain human action), but, as Harcourt suggests, there are some we cannot. Some mental health issues we can only see as caused rather than as expressing internal psychological conflicts.

Harcourt is clear that the contrast he discusses cannot be used as a development standard, but he does not rule out psychoanalysis developing its own theory of maturation as long as this theory has a different kind of basis. But it seems to me that psychoanalysts are most unlikely to want to do this – for precisely the reasons Harcourt brings out. Psychoanalysis sees humans as being full of contradictions, but it believes those contradictions can (at least to some extent) be sorted out. If we move to a less conflicted relationship with other people and with ourselves, our mental health will improve and we will be able to live more satisfying lives. But psychoanalysts are not moral philosophers. They do not flesh out their vision with lots of prescriptive detail. Indeed, different psychoanalytic thinkers offer (slightly) different accounts of what human flourishing involves. They are united, however, in seeing (certain kinds of) mental health issues as reflecting the negative impact on the individual’s life of their failure to face up to the truth about themselves. The concept of human flourishing captures this very well. The focus is not on following moral rules, but on living a life closer to what a good life can be for human beings. This approach fuses together mental health, living well and maturity. But the converse phrase “mad, bad and immature” captures this imperfectly. Infants are not mad, they are just at the start of the path towards what adulthood can be. They are not bad, they are just not yet flourishing, and they are only immature in the sense that they have a long road ahead of them. One might say similar things about adults except one would expect adults to have made at least some progress in their journey and the flourishing element takes on a more moral dimension, since our failure to “flourish” as adults has impacts on others as well as on ourselves.

But is this ill-defined vision of human flourishing achievable? Has anyone ever managed to eliminate their internal contradictions and achieve perfect mental health? Of course not. It is an ideal, not an achievable goal. As Harcourt notes, psychoanalysts tend not to talk about their Aristotelianism, but what they say indicates that their work is based on an ideal of how people should live. For example, most would agree that there is no such thing as being fully analysed. In other words, no one is ever fully mentally well, fully flourishing or fully mature. Our contradictions are so ingrained that it can only ever be a matter of trying to find better ways of living with them. The daily experience of trying to help people who have such a strong sense of not flourishing that they have opted for therapy gives analysts a real sense of how difficult people find it to face up to the truth about themselves. Their patients may be so locked into their early patterns of relating that nothing the analyst can say or do (over the course of years) can stop the patient treating them as if they were their mother or father. Doesn’t this deserve to be called madness? And if so, aren’t all of us to a greater or less extent mad? Not literally mad, of course. To be what we normally call “mad”, a patient would have to believe that their analyst really was their parent. And fortunately, that is not common.